Provider Demographics
NPI:1801094578
Name:ANDERSON, MARCUS WALTER (MD)
Entity type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:WALTER
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5784
Mailing Address - Country:US
Mailing Address - Phone:904-819-4040
Mailing Address - Fax:904-819-4041
Practice Address - Street 1:400 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5784
Practice Address - Country:US
Practice Address - Phone:904-819-4565
Practice Address - Fax:904-819-4999
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN109982084P0800X
FLME1058402084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116379300Medicaid
FL14N4NOtherBCBS
FL116379300Medicaid